HomeMy WebLinkAboutApp-License-Certifications The Commonwealth of Massachusetts Fee
Town of Yarmouth $0.00
Food Establishment License
Number: BOHF-15-1836-07 Issue Date: 1/1/2022
Mailing Address: Location'Address:
DENNIS-YARMOUTH REGIONAL SCHOOL DISTRICT 400 HIGGINS CROWELL RD
MATTACHEESE MIDDLE SCHOOL WEST YARMOUTH, MA 02673
400 HIGGINS CROWELL ROAD
WEST YARMOUTH, MA 02673
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Non-Profit;
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
Of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston1111
�I
Bruce G. Murphy, MPH, R.S CH,'I James G.Gardiner
Health Director/Assistant Health Director
damTOWN OF YARMOUTH BOARD OF HEALTH
F , APPLICATION FOR LICENSE/PERMIT -2022
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: 104/4hm9-c/ s�Ma j LL a&- TAX ID:
LOCATION ADDRESS: % i—t c,.w Cl2euiat TEL.#: 5-7) r-7P-79
MAILING ADDRESS: W23T J//ht, u 7T/, m/t ONv 73
E-MAIL ADDRESS: Pou1'g..c, @ d y-repoo kil,,yta i ic.,c
OWNER NAME: CA-aot- cwotJa_gu2 L1
CORPORATION NAME IF APPLICAB E): Dcyoutli phz/pfar771 sTg/6--
MANAGER'S NAME: o &v Po WE)2S TEEM: -3 9 tr-77 2-6
MAILING ADDRESS: a29b s a4v, 5114.r7l egmw4.774 ,4e4 0)- /-
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please ist the designated
Pool Operator(s) and attach a copy of the certification to this form. APR 2 6 2022
1. 2.
HEAL! H LDEPT.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
yearsrecords. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. / ii VI SCervtio 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1. P-142C/_ Vic cc-6-66 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. J/h'v.L1- I!/s cez-zri, 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
w
1. 147,62(51-. ��c G 2.
3. 4.
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to
the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants
must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall
generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days
within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient.
Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as
amended, shall generally be considered Transient.
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the
Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to
opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State
certified lab, and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health
Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health
Department, or from the Town's website at www.varmouth.ma.us under Health Department,Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to
the Health Department. Failure to do so will result m the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFÉS:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
TOBACCO PRODUCT PERMIT CAP
A tobacco permit holder who has failed to renew his or her permit within thirty(30) days of the previous year's
permit expiration date is considered an expired license, and the tobacco_license cap is reduced.
Department of Industrial Accidents
- 1111111( Office of Investigations
_ _V.
� 1 Congress Street, Suite. 100
e — Boston, MA 02114-2017
‘.1.4 7,74 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: t yVNri )/452i•rida71-I g,-(F10,uAL 5Ci/ )- 2,i Dzic-J
Address: oz96 -7>'rn,tJ /11/610
City/State/Zip: S rt,e-rl-I y/IR,stdcc77-1 ,4t4 a4q Phone #: 5-tiY - 3'(1,?? - '7 6 Op
Are yo n employer?Check the appropriate box: Business Type(required):
1. I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. E Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. E] Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other 1,7)1,XC.9770/
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
-ganization should check box#1.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
isurance Company Name: GU 4 Di A--,t' C-</h,'u. cSJ72W(&
surer's Address: PO L0Y 13
;ity/State/Zip: c/UO c RA) M4 0•2z c/"
L l U C-00 oil Expiration /.;"0/4)141,;2-2--L
'olicy#or Self-ins.Lic.# Date: t
►ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
rivestigations of the DIA for insurance coverage verification.
do hereby certify, under the pains and penalties of perjuty that the information provided above is true and correct.
signature: Date: //// .'-2-
'hone#: 5z e 39 e 7e CSL:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617727-7749
www.mass.gov/dia
orm Revised 7/2010
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